What specialty does the ailment belong to?

[Daimon Michiko Doctor X]

A couple of attendings and I were debating who is the best to call in case of these ailments: osteomyelitis and meningitis. Some people said OM is more of internal medicine's job others said they'd call orthopaedics. Same for meningitis who are you calling. Others said internal medicine , some said ID.

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[Raryn]

Outside of a few centers with regards to HIV, ID doesn't have a primary service.

Outside of super stable perioperative patients without comorbidities, ortho typically doesn't like to admit patients.

Both of those patients would be admitted to medicine with the potential of ID (if the antibiotic choice isn't clear) or Ortho/Neurosurg/Vascular/Podiatry (if the patient needs an operation for their osteo) as a consult.

I've taken care of a ton of meningitis, and typically call ID if it isn't completely clear, generally anything other than just a typical first episode of HSV, strep pneumo, or NG meningitis. Recurrent HSV meningitis (mollaret's), TB meningitis, fungal meningitis (though the tenth time you take care of crypto meningitis it isn't particularly complicated), legionella meningitis (when to add the aminoglycoside), etc. But I'm still the primary one responsible (as the internist).

 

[tiedyeddog]

Both of those should be internal medicine. Ortho/neurosurgery should only be consulted on the osteo case as most cases are never operative.

Meningitis is internal med with an ID consult unless ID has a service are your hospital. Unless gen med wants to handle it themselves, however they see fit.


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[Winged Scapula]

Agree with my colleagues above.

IM for both with Ortho/ID consultations.

 

[Psai]

Osteo to ortho. Meningitis to neurology. If really sick then icu.

 

[colbgw02]

Osteo to ortho. Meningitis to neurology. If really sick then icu.

Yeah, seems like most of the LPs I do for meningitis are coming from neurology.

I do a bunch of biopsies/aspirations for osteomyelitis/septic arthritis. It's almost always coming from IM/hospitalist following an ortho or ID (or both) consult.

 

[Raryn]

Osteo to ortho. Meningitis to neurology. If really sick then icu.

It's variable locale to locale whether neurology has it's own primary service. Where I trained, they were busy enough with consults everything just went to IM, from strokes to MS flares to whatever. I'll agree it's not unreasonable to admit to neuro if they have a service though.

OTOH, I've never seen ortho admit an osteomyelitis. They, neurosurg, vascular surg, or podiatry get consulted depending on the bone, but as a primary patient? Maybe our orthopods were just lazier than the norm.

 

[evilbooyaa]

I'd think meningitis was Neuro (if they have an admitting service), otherwise IM.

OM is IM 100% of the time. It's an infection first. C/s ortho or vascular if necessary.

 

[Slack3r]

It's variable locale to locale whether neurology has it's own primary service. Where I trained, they were busy enough with consults everything just went to IM, from strokes to MS flares to whatever. I'll agree it's not unreasonable to admit to neuro if they have a service though.

OTOH, I've never seen ortho admit an osteomyelitis. They, neurosurg, vascular surg, or podiatry get consulted depending on the bone, but as a primary patient? Maybe our orthopods were just lazier than the norm.

No reason osteo needs to be on a surgical primary service. As above, most aren't operative, and if even if they are, the surgical mgmt generally ends at debridement.

 

[ProfMD]

Medicine +/- ID consult for osteo. Only call a surgeon if you think the patient needs surgery. Even then the patient will go back to medicine postop.

No reason for neurology to see meningitis unless the patient develops complications. Medicine +/- ID consult for this one too.

 

[kchan99]

Usually medicine + ID, then neurology +/- IR if difficult LP, neurology if encephalopathy, seizure, stroke, etc., Neurosurgery if patient happens to have a shunt or need a subarachnoid drain, external ventricular drain, shunt... MICU or NICU if unstable or need frequent LPs

 

[tiedyeddog]

Usually medicine + ID, then neurology +/- IR if difficult LP, neurology if encephalopathy, seizure, stroke, etc., Neurosurgery if patient happens to have a shunt or need a subarachnoid drain, external ventricular drain, shunt... MICU or NICU if unstable or need frequent LPs

If the patient has a shunt with Meningitis then it should come to the neurosurgery service. We have to externalize those or at worst place an external drain. Will be in the hospital for more than a week like that, sometimes two or three so we own it.


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[Psai]

If the patient has a shunt with Meningitis then it should come to the neurosurgery service. We have to externalize those or at worst place an external drain. Will be in the hospital for more than a week like that, sometimes two or three so we own it.


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Tell that to our neurosurgery service.

 

[tiedyeddog]

Tell that to our neurosurgery service.

Guess my program is a little more old school than some others.

 

[TooMuchResearch]

If the patient has a shunt with Meningitis then it should come to the neurosurgery service. We have to externalize those or at worst place an external drain. Will be in the hospital for more than a week like that, sometimes two or three so we own it.


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That is neurosurgery service dependent.

I'll call you (neurosurgery), but you might tell me to admit to medicine/critical care/neuro intensivist depending on hospital and on call surgeon.

 

[tiedyeddog]

That is neurosurgery service dependent.

I'll call you (neurosurgery), but you might tell me to admit to medicine/critical care/neuro intensivist depending on hospital and on call surgeon.

Perhaps, but n=1 at my specific institution if it is PROVEN a shunt is infected via CSF we always take it on our service and externalize. Was the same at every place I did a sub-I at as well.

Our NCCU isn't a service itself and requires stroke, neurology, or neurosurgery to be the primary.

 

[rokshana]

Perhaps, but n=1 at my specific institution if it is PROVEN a shunt is infected via CSF we always take it on our service and externalize. Was the same at every place I did a sub-I at as well.

Our NCCU isn't a service itself and requires stroke, neurology, or neurosurgery to be the primary.

i think i speak for everyone here...we wish you were at our respective hospitals...

 

[Psai]

Perhaps, but n=1 at my specific institution if it is PROVEN a shunt is infected via CSF we always take it on our service and externalize. Was the same at every place I did a sub-I at as well.

Our NCCU isn't a service itself and requires stroke, neurology, or neurosurgery to be the primary.

Hm we had a proven infected shunt that was externalized that day and somehow it was pushed to medicine

 

[tiedyeddog]

Hm we had a proven infected shunt that was externalized that day and somehow it was pushed to medicine

Sounds bush league, we're neurosurgeons not orthopods

 

[Slack3r]

Sounds bush league, we're neurosurgeons not orthopods

 

[Raryn]

Hm we had a proven infected shunt that was externalized that day and somehow it was pushed to medicine

I had that three or four times as a resident. Even getting it externalized was like pulling teeth, usually the ID consultant had to practically beg the neurosurgeon to do the procedure on the patient.

But we also didn't have a neurosurgery residency program, so it was just a semi-academic group and their PAs.

 

[tiedyeddog]

I had that three or four times as a resident. Even getting it externalized was like pulling teeth, usually the ID consultant had to practically beg the neurosurgeon to do the procedure on the patient.

But we also didn't have a neurosurgery residency program, so it was just a semi-academic group and their PAs.

Externalization doesn't pay like an un-indicated lumbar fusion I'm afraid.